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  1. Liew SC
    Rev Assoc Med Bras (1992), 2016 Feb;62(1):90-100.
    PMID: 27008500 DOI: 10.1590/1806-9282.62.01.90
    folic acid is a water soluble vitamin, which is synthetically-produced and found in fortified foods and supplements. Folate is found naturally in plants, such as the dark green leafy vegetables. Folate is not synthesizedde novo by humans, therefore the daily requirements are met from the dietary intake of folic acid supplements or food rich in this vitamin. Folate deficiency could lead to numerous common health problems. Hyperhomocysteinemia and the possibility of malignancy developments are the long term consequences of this deficit albeit contradictory findings on these claims.
  2. Liew SC, Aung T
    Sleep Med, 2021 01;77:192-204.
    PMID: 32951993 DOI: 10.1016/j.sleep.2020.07.048
    Sleep deprivation, a consequence of multiple health problems or a cause of many major health risks, is a significant public health concern in this era. In the recent years, numerous reports have been added to the literature to provide explanation and to answer previously unanswered questions on this important topic but comprehensive updates and reviews in this aspect remain scarce. The present study identified 135 papers that investigated the association between sleep deprivation and health risks, including cardiovascular, respiratory, neurological, gastrointestinal, immunology, dermatology, endocrine, and reproductive health. In this review, we aimed to provide insight into the association between sleep deprivation and the development of diseases. We reviewed the latest updates available in the literature and particular attention was paid to reports that detailed all possible causal relationships involving both extrinsic and intrinsic factors that may be relevant to this topic. Various mechanisms by which sleep deprivation may affect health were presented and discussed, and this review hopes to serve as a platform for ideas generation for future research.
  3. Liew SC, Gupta ED
    Eur J Med Genet, 2015 Jan;58(1):1-10.
    PMID: 25449138 DOI: 10.1016/j.ejmg.2014.10.004
    The Methylenetetrahydrofolate reductase (MTHFR) C677T polymorphism is associated with various diseases (vascular, cancers, neurology, diabetes, psoriasis, etc) with the epidemiology of the polymorphism of the C677T that varies dependent on the geography and ethnicity. The 5,10-Methylenetetrahydrofolate reductase (MTHFR) locus is mapped on chromosome 1 at the end of the short arm (1p36.6). This enzyme is important for the folate metabolism which is an integral process for cell metabolism in the DNA, RNA and protein methylation. The mutation of the MTHFR gene which causes the C677T polymorphism is located at exon 4 which results in the conversion of valine to alanine at codon 222, a common polymorphism that reduces the activity of this enzyme. The homozygous mutated subjects have higher homocysteine levels while the heterozygous mutated subjects have mildly raised homocysteine levels compared with the normal, non-mutated controls. Hyperhomocysteinemia is an emerging risk factor for various cardiovascular diseases and with the increasing significance of this polymorphism in view of the morbidity and mortality impact on the patients, further prevention strategies and nutritional recommendations with the supplementation of vitamin B12 and folic acid which reduces plasma homocysteine level would be necessary as part of future health education. This literature review therefore focuses on the recent evidence-based reports on the associations of the MTHFR C677T polymorphism and the various diseases globally.
  4. Liew SC, Liew SW, Zain JM
    J Digit Imaging, 2013 Apr;26(2):316-25.
    PMID: 22555905 DOI: 10.1007/s10278-012-9484-4
    Tamper localization and recovery watermarking scheme can be used to detect manipulation and recover tampered images. In this paper, a tamper localization and lossless recovery scheme that used region of interest (ROI) segmentation and multilevel authentication was proposed. The watermarked images had a high average peak signal-to-noise ratio of 48.7 dB and the results showed that tampering was successfully localized and tampered area was exactly recovered. The usage of ROI segmentation and multilevel authentication had significantly reduced the time taken by approximately 50 % for the tamper localization and recovery processing.
  5. Liew SC, Sidhu J, Barua A
    BMC Med Educ, 2015;15:44.
    PMID: 25889887 DOI: 10.1186/s12909-015-0327-0
    Learning styles and approaches of individual undergraduate medical students vary considerably and as a consequence, their learning needs also differ from one student to another. This study was conducted to identify different learning styles and approaches of pre-clinical, undergraduate medical students and also to determine the relationships of learning preferences with performances in the summative examinations.
  6. Khor HL, Liew SC, Zain JM
    Int J Biomed Imaging, 2016;2016:9583727.
    PMID: 26981111 DOI: 10.1155/2016/9583727
    With the advancement of technology in communication network, it facilitated digital medical images transmitted to healthcare professionals via internal network or public network (e.g., Internet), but it also exposes the transmitted digital medical images to the security threats, such as images tampering or inserting false data in the images, which may cause an inaccurate diagnosis and treatment. Medical image distortion is not to be tolerated for diagnosis purposes; thus a digital watermarking on medical image is introduced. So far most of the watermarking research has been done on single frame medical image which is impractical in the real environment. In this paper, a digital watermarking on multiframes medical images is proposed. In order to speed up multiframes watermarking processing time, a parallel watermarking processing on medical images processing by utilizing multicores technology is introduced. An experiment result has shown that elapsed time on parallel watermarking processing is much shorter than sequential watermarking processing.
  7. Khor HL, Liew SC, Zain JM
    J Digit Imaging, 2017 Jun;30(3):328-349.
    PMID: 28050716 DOI: 10.1007/s10278-016-9930-9
    Tampering on medical image will lead to wrong diagnosis and treatment, which is life-threatening; therefore, digital watermarking on medical image was introduced to protect medical image from tampering. Medical images are divided into region of interest (ROI) and region of non-interest (RONI). ROI is an area that has a significant impact on diagnosis, whereas RONI has less or no significance in diagnosis. This paper has proposed ROI-based tamper detection and recovery watermarking scheme (ROI-DR) that embeds ROI bit information into RONI least significant bits, which will be extracted later for authentication and recovery process. The experiment result has shown that the ROI-DR has achieved a good result in imperceptibility with peak signal-to-noise ratio (PSNR) values approximately 48 dB, it is robust against various kinds of tampering, and the tampered ROI was able to recover to its original form. Lastly, a comparative table with the previous research (TALLOR and TALLOR-RS watermarking schemes) has been derived, where these three watermarking schemes were tested under the same testing conditions and environment. The experiment result has shown that ROI-DR has achieved speed-up factors of 22.55 and 26.65 in relative to TALLOR and TALLOR-RS watermarking schemes, respectively.
  8. Miettinen J, Shi C, Liew SC
    Environ Manage, 2017 10;60(4):747-757.
    PMID: 28674917 DOI: 10.1007/s00267-017-0911-7
    In this paper, we analyze the spatio-temporal distribution of vegetation fires in Peninsular Malaysia, Sumatra, and Borneo in the severe El Niño year of 2015, concentrating on the distribution of fires between mineral soils and peatland areas, and between land cover types in peatland areas. The results reveal that 53% of all Moderate Resolution Imaging Spectroradiometer (MODIS) fire detections were recorded in peatlands that cover only 12% of the study area. However, fire occurrence in the peatland areas was highly dependent on land cover type. Pristine peat swamp forests (PSF) experienced only marginal fire activity (30 fire detections per 1000 km2) compared to deforested undeveloped peatlands (831-915 fire detections per 1000 km2). Our results also highlight the extreme fire vulnerability of the southern Sumatran and Bornean peatlands under strong El Niño conditions: 71% of all peatland hotspots were detected in the provinces of South Sumatra and Central Kalimantan, which contain 29% of peatlands in the study area. Degraded PSF and all deforested peatland land cover types, including managed areas, in the two provinces were severely affected, demonstrating how difficult it is to protect even managed drained agricultural areas from unwanted fires during dry periods. Our results thereby advocate rewetting and rehabilitation as the primary management option for highly fire prone degraded undeveloped peatland areas, whenever feasible, as a means to reduce fire risk during future dry episodes.
  9. Liew SC, Naik V, Azim DHF
    Med Sci Educ, 2021 Dec;31(6):1889-1894.
    PMID: 34956703 DOI: 10.1007/s40670-021-01433-5
    Pathology teaching, an intensively image loaded discipline, poses a significant challenge in its delivery. A lot of effort has been placed into sourcing teaching methods that could effectively enhance students' understanding and knowledge retention in this discipline. We describe for the first time in the literature the use of an image-based quiz (IBQ) to deliver a neuropathology lecture. The participating medical students were randomised into either the study group (IBQ) or the control group (traditional lecture, TL). The students were asked to complete the pre- and post-multiple choice question (MCQ) test before and after attending either of the allocated interventions. In the IBQ group, the students were presented with image-based quizzes, and answers to the quizzes were projected in real-time on screen. The students in the TL group were given the usual, traditional lecture. A total of 75 third-year medical students participated in this study. The participants were recruited from third-year medical students representing two different academic years. There was no significant difference in the pre- and post-MCQ scores between the IBQ and TL groups. However, a significant improvement in the mean scores for the pre- and post-MCQ results in both the study (p = 0.001; 95% CI 0.572-1.954) and control (p 
  10. Badshah G, Liew SC, Zain JM, Ali M
    J Digit Imaging, 2016 Apr;29(2):216-25.
    PMID: 26429361 DOI: 10.1007/s10278-015-9822-4
    In teleradiology, image contents may be altered due to noisy communication channels and hacker manipulation. Medical image data is very sensitive and can not tolerate any illegal change. Illegally changed image-based analysis could result in wrong medical decision. Digital watermarking technique can be used to authenticate images and detect as well as recover illegal changes made to teleradiology images. Watermarking of medical images with heavy payload watermarks causes image perceptual degradation. The image perceptual degradation directly affects medical diagnosis. To maintain the image perceptual and diagnostic qualities standard during watermarking, the watermark should be lossless compressed. This paper focuses on watermarking of ultrasound medical images with Lempel-Ziv-Welch (LZW) lossless-compressed watermarks. The watermark lossless compression reduces watermark payload without data loss. In this research work, watermark is the combination of defined region of interest (ROI) and image watermarking secret key. The performance of the LZW compression technique was compared with other conventional compression methods based on compression ratio. LZW was found better and used for watermark lossless compression in ultrasound medical images watermarking. Tabulated results show the watermark bits reduction, image watermarking with effective tamper detection and lossless recovery.
  11. Badshah G, Liew SC, Zain JM, Ali M
    J Med Imaging (Bellingham), 2016 Jan;3(1):017001.
    PMID: 26839914 DOI: 10.1117/1.JMI.3.1.017001
    The open accessibility of Internet-based medical images in teleradialogy face security threats due to the nonsecured communication media. This paper discusses the spatial domain watermarking of ultrasound medical images for content authentication, tamper detection, and lossless recovery. For this purpose, the image is divided into two main parts, the region of interest (ROI) and region of noninterest (RONI). The defined ROI and its hash value are combined as watermark, lossless compressed, and embedded into the RONI part of images at pixel's least significant bits (LSBs). The watermark lossless compression and embedding at pixel's LSBs preserve image diagnostic and perceptual qualities. Different lossless compression techniques including Lempel-Ziv-Welch (LZW) were tested for watermark compression. The performances of these techniques were compared based on more bit reduction and compression ratio. LZW was found better than others and used in tamper detection and recovery watermarking of medical images (TDARWMI) scheme development to be used for ROI authentication, tamper detection, localization, and lossless recovery. TDARWMI performance was compared and found to be better than other watermarking schemes.
  12. Koh LP, Miettinen J, Liew SC, Ghazoul J
    Proc Natl Acad Sci U S A, 2011 Mar 22;108(12):5127-32.
    PMID: 21383161 DOI: 10.1073/pnas.1018776108
    Rising global demands for food and biofuels are driving forest clearance in the tropics. Oil-palm expansion contributes to biodiversity declines and carbon emissions in Southeast Asia. However, the magnitudes of these impacts remain largely unquantified until now. We produce a 250-m spatial resolution map of closed canopy oil-palm plantations in the lowlands of Peninsular Malaysia (2 million ha), Borneo (2.4 million ha), and Sumatra (3.9 million ha). We demonstrate that 6% (or ≈880,000 ha) of tropical peatlands in the region had been converted to oil-palm plantations by the early 2000s. Conversion of peatswamp forests to oil palm led to biodiversity declines of 1% in Borneo (equivalent to four species of forest-dwelling birds), 3.4% in Sumatra (16 species), and 12.1% in Peninsular Malaysia (46 species). This land-use change also contributed to the loss of ≈140 million Mg of aboveground biomass carbon, and annual emissions of ≈4.6 million Mg of belowground carbon from peat oxidation. Additionally, the loss of peatswamp forests implies the loss of carbon sequestration service through peat accumulation, which amounts to ≈660,000 Mg of carbon annually. By 2010, 2.3 million ha of peatswamp forests were clear-felled, and currently occur as degraded lands. Reforestation of these clearings could enhance biodiversity by up to ≈20%, whereas oil-palm establishment would exacerbate species losses by up to ≈12%. To safeguard the region's biodiversity and carbon stocks, conservation and reforestation efforts should target Central Kalimantan, Riau, and West Kalimantan, which retain three-quarters (3.9 million ha) of the remaining peatswamp forests in Southeast Asia.
  13. Liew SC, Sow CF, Sidhu J, Nadarajah VD
    Med Educ Online, 2015;20:27959.
    PMID: 26356229 DOI: 10.3402/meo.v20.27959
    BACKGROUND: While there is an increasing pool of literature documenting the benefits of near-peer tutoring programme, little is known about the benefits for junior and senior peer tutors. Knowledge of the peer tutors' perceived benefits at different levels of seniority will aid in the development of a near-peer tutoring programme that will better fulfil both curricula and personal aspirations of near-peer tutors. We, therefore, investigated the perceived benefits of participation in a near-peer tutoring programme for junior as well as senior near-peer tutors.

    METHODS: Pre- and post-participation questionnaires were distributed to near-peer tutors after their clinical skills teaching sessions with Phase I undergraduate medical students. The Peer Tutor Assessment Instrument questionnaires were distributed to the 1) students, and to the 2) near-peer tutors (junior and senior) after each teaching and learning session for self-evaluation.

    RESULTS: The senior near-peer tutors felt that their participation in the programme had enhanced their skills (p=0.03). As a whole, the near-peer tutors were more motivated (Pre 5.32±0.46; Post 5.47±0.50; p=0.210) to participate in future teaching sessions but did not expect that having teaching experiences would make teaching as their major career path in the future (Pre 4.63±1.07; Post 4.54±0.98; p=0.701). The senior near-peer tutors were evaluated significantly higher by the students (p=0.0001). Students' evaluations of near-peer tutors on the domain of critical analysis was higher than self-evaluations (p=0.003).

    CONCLUSIONS: Generally, the near-peer tutors perceived that they have benefited most in their skills enhancement and these near-peer tutors were scored highly by the students. However, senior near-peer tutors do not perceive that the programme has a lasting impact on their choice of career path.

  14. Liew SC, Dutta S, Sidhu JK, De-Alwis R, Chen N, Sow CF, et al.
    Med Teach, 2014 Jul;36(7):626-31.
    PMID: 24787534 DOI: 10.3109/0142159X.2014.899689
    The complexity of modern medicine creates more challenges for teaching and assessment of communication skills in undergraduate medical programme. This research was conducted to study the level of communication skills among undergraduate medical students and to determine the difference between simulated patients and clinical instructors' assessment of communication skills.
  15. Liew SC, Das-Gupta E, Chakravarthi S, Wong SF, Lee N, Safdar N, et al.
    BMC Res Notes, 2012;5:201.
    PMID: 22537619 DOI: 10.1186/1756-0500-5-201
    Angiogenesis has been reported to be one of the contributory factors to the pathogenesis of psoriasis vulgaris. This study aims to compare the expression of different angiogenesis growth factors namely (1) the vascular endothelial growth factor (VEGF) subfamily: A, B, C, D and placenta growth factor (PlGF); (2) nerve growth factor (NGF) and (3) von Willebrand factor (vWFr) in the skins of patients with psoriasis vulgaris and non-psoriatic volunteers.

    Study site: Dermatology Department of Hospital Kuala Lumpur, Kuala Lumpur and Tuanku Ja’afar Hospital, Seremban, Malaysia
  16. Spooner M, Larkin J, Liew SC, Jaafar MH, McConkey S, Pawlikowska T
    BMC Med Educ, 2023 Nov 22;23(1):895.
    PMID: 37993832 DOI: 10.1186/s12909-023-04842-9
    INTRODUCTION: While feedback aims to support learning, students frequently struggle to use it. In studying feedback responses there is a gap in explaining them in relation to learning theory. This study explores how feedback experiences influence medical students' self-regulation of learning.

    METHODS: Final-year medical students across three campuses (Ireland, Bahrain and Malaysia) were invited to share experiences of feedback in individual semi-structured interviews. The data were thematically analysed and explored through the lens of self-regulatory learning theory (SRL).

    RESULTS: Feedback interacts with learners' knowledge and beliefs about themselves and about learning. They use feedback to change both their cognitive and behavioural learning strategies, but how they choose which feedback to implement is complex. They struggle to generate learning strategies and expect teachers to make sense of the "how" in addition to the "what"" in planning future learning. Even when not actioned, learners spend time with feedback and it influences future learning.

    CONCLUSION: By exploring our findings through the lens of self-regulation learning, we advance conceptual understanding of feedback responses. Learners' ability to generate "next steps" may be overestimated. When feedback causes negative emotions, energy is diverted from learning to processing distress. Perceived non-implementation of feedback should not be confused with ignoring it; feedback that is not actioned often impacts learning.

  17. Liew SC, Pallath V, Rasali Y, Foong CC, Hong WH, Tan MP
    PLoS One, 2023;18(12):e0289176.
    PMID: 38117842 DOI: 10.1371/journal.pone.0289176
    INTRODUCTION: During the coronavirus disease 2019 (COVID-19) pandemic, the use of virtual consultations has accelerated to ensure continued access to healthcare despite lockdowns and physical distancing measures. We aimed to determine the knowledge (awareness) of, attitude (acceptability) to, and practice (exposure) [KAP] of virtual consultations (VC), the demographic factors associated with poor KAP, and the correlation between the three KAP domains.

    METHODS: A cross-sectional study, using a convenience sampling technique, was conducted from 13 September, 2021 to 28 November, 2021. We designed a 45-item VC KAP questionnaire. This was distributed to outpatient users attending cardiovascular, dermatology, geriatrics, haematology, endocrine, respiratory, gastroenterology, rheumatology, or neurology clinics at the University Malaya Medical Centre. It was completed during face-to-face, online, or telephone interviews. The data were analysed using SPSS version 24.0. Binary logistic regression was used to determine the demographic factors associated with KAP. Correlation between KAP domains was determined using Spearman's rho (r). A p-value of <0.05 was considered statistically significant.

    RESULTS: A total of 366 questionnaires were completed. Knowledge (awareness), attitude (acceptability), and practice (exposure) were considered good in 69.7%, 80.9%, and 24.6% of participants, respectively. There were no significant relationships between age, gender, ethnicity, and duration of hospital attendance (years) with knowledge (awareness), attitude (acceptability), and practice (exposure). A moderate positive correlation was seen between knowledge (awareness) and attitude (acceptability) (Attitude total [Atotal]) (r = 0.48, p<0.001), with no significant correlation between knowledge (awareness) and practice (exposure) (r = 0.04, p = 0.45), and attitude (acceptability) (Atotal) and practice (r = 0.01, p = 0.82).

    CONCLUSION: Overall, outpatient clinic users had good knowledge (awareness) of and were receptive towards VC but had poor practice (exposure). More opportunities for VC use in healthcare can increase exposure and subsequent utilisation. Interventions to increase the effectiveness of VC use should be explored in future studies.

  18. Liew SC, Das-Gupta E, Wong SF, Lee N, Safdar N, Jamil A
    Nutr J, 2012 Jan 05;11:1.
    PMID: 22217364 DOI: 10.1186/1475-2891-11-1
    BACKGROUND: The methylenetetrahydrofolate reductase (MTHFR) enzyme catalyzes the reduction of 5, 10-methylenetetrahydrofolate to 5-methyltetrahydrofolate and methyl donors. The methyl donors are required for the conversion of homocysteine to methionine. Mutation of MTHFR 677 C > T disrupts its thermostability therefore leads to defective enzyme activities and dysregulation of homocysteine levels.

    METHODS: This case-control study (n = 367) was conducted to investigate the correlation of the MTHFR gene polymorphism [NM_005957] and psoriasis vulgaris amongst the Malaysian population. Overnight fasting blood samples were collected from a subgroup of consented psoriasis vulgaris patients and matched controls (n = 84) for the quantification of homocysteine, vitamin B12 and folic acid levels.

    RESULTS: There was no significant increase of the MTHFR 677 C > T mutation in patients with psoriasis vulgaris compared with controls (χ(2) = 0.733, p = 0.392). No significant association between homocysteine levels and MTHFR gene polymorphism in cases and controls were observed (F = 0.91, df = 3, 80, p = 0.44). However, homocysteine levels in cases were negatively correlated with vitamin B12 (r = -0.173) and folic acid (r = -0.345) levels. Vitamin B12 and folic acid levels in cases were also negatively correlated (r = -0.164).

    CONCLUSIONS: Our results indicate that there was no significant association between the MTHFR gene polymorphism and psoriasis vulgaris in the Malaysian population. There was no significant increase of the plasma homocysteine level in the psoriasis patients compared to the controls.

  19. Liew SC, Tan MP, Breen E, Krishnan K, Sivarajah I, Raviendran N, et al.
    BMC Med Educ, 2023 Oct 25;23(1):796.
    PMID: 37880711 DOI: 10.1186/s12909-023-04777-1
    BACKGROUND: Virtual consultation is a synchronous mode of telemedicine provided remotely via information and communication technology. The projected growth of digitalization in healthcare delivery, however, necessitates medical student training in virtual consultation (VC) to ensure safe and effective patient care. This study describes the implementation and preliminary evaluation of a competency-based VC training module for undergraduate medical students.

    METHODS: A newly developed six-week VC module was implemented online through asynchronous microlearning and synchronous simulation-based experiential learning modalities. Clinical students in years 4 and 5 and fresh graduates, who had not started pre-registration house officer or residency programmes, were invited to participate. Training outcomes using checklist-based video-recorded assessments of VC encounters between medical students and simulated patients were compared. Each video was independently assessed by two facilitators trained in VC teaching and assessment, using a direct observed virtual consultation skills checklist derived from established VC competencies. The participants completed course evaluations electronically as additional outcome measures.

    RESULTS: Fifty-two clinical phase medical students and alumni completed both the instructional and practical phases of this module. Altogether, 45 (95.7%) students found the module beneficial, and 46 (95.9%) reported increased self-efficacy for conducting VC. In total, 46 (95.9%) students would recommend the course to others. Post-test results showed a significant increase in the students' abilities to conduct a VC (t-test = 16.33, p 

  20. Wijedasa LS, Jauhiainen J, Könönen M, Lampela M, Vasander H, Leblanc MC, et al.
    Glob Chang Biol, 2017 03;23(3):977-982.
    PMID: 27670948 DOI: 10.1111/gcb.13516
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